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Procalcitonin to Reduce Antibiotic Exposure During Acute Chest Syndrome in Adult Patients with Sickle-Cell Disease

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Procalcitonin to Reduce Antibiotic Exposure During Acute Chest Syndrome in Adult Patients with Sickle-Cell Disease Journal of Clinical Medicine Article Procalcitonin to Reduce Antibiotic Exposure during Acute Chest Syndrome in Adult Patients with Sickle-Cell Disease 1,2, , 1,2, 1,2 3 Keyvan Razazi * y,Ségolène Gendreau y , Elise Cuquemelle , Mehdi Khellaf , Constance Guillaud 4, Bertrand Godeau 5, Giovanna Melica 6, Stéphane Moutereau 7, Camille Gomart 8, Slim Fourati 8 , Nicolas De Prost 1,2,9, Guillaume Carteaux 1,2,9, Christian Brun-Buisson 1,2, Pablo Bartolucci 9,10, Anoosha Habibi 9,10 and Armand Mekontso Dessap 1,2,9 1 DHU A-TVB, Service de Médecine Intensive Réanimation, 51 Avenue du Maréchal de Lattre de Tassigny, AP-HP Hôpitaux Universitaires Henri Mondor, 94010 Créteil, France; [email protected] (S.G.); [email protected] (E.C.); [email protected] (N.D.P.); [email protected] (G.C.); [email protected] (C.B.-B.); [email protected] (A.M.D.) 2 IMRB, GRC CARMAS, Faculté de Santé de Créteil, Université Paris Est Créteil, 51 Avenue du Maréchal de Lattre de Tassigny, 94010 Créteil, France 3 Service d’Accueil des Urgences, AP-HP Hôpitaux Universitaires Henri Mondor, 51 Avenue du Maréchal de Lattre de Tassigny, 94010 Créteil, France; [email protected] 4 Département d’Aval des Urgences, AP-HP Hôpitaux Universitaires Henri Mondor, 51 Avenue du Maréchal de Lattre de Tassigny, 94010 Créteil, France; [email protected] 5 Service de Médecine Interne, AP-HP Hôpitaux Universitaires Henri Mondor, 51 Avenue du Maréchal de Lattre de Tassigny, 94010 Créteil, France; [email protected] 6 Service d’Immunologie Clinique et Maladies Infectieuses, AP-HP Hôpitaux Universitaires Henri Mondor, 51 Avenue du Maréchal de Lattre de Tassigny, 94010 Créteil, France; [email protected] 7 Service de Biochimie, AP-HP Hôpitaux Universitaires Henri Mondor, 51 Avenue du Maréchal de Lattre de Tassigny, 94010 Créteil, France; [email protected] 8 Département de Virologie, Bactériologie, Parasitologie-Mycologie, AP-HP Hôpitaux Universitaires Henri Mondor, 51 Avenue du Maréchal de Lattre de Tassigny, 94010 Créteil, France; [email protected] (C.G.); [email protected] (S.F.) 9 Unité U955, INSERM, Université Paris Est, 94010 Créteil, France; [email protected] (P.B.); [email protected] (A.H.) 10 French Sickle Cell Referral Center, Laboratory of Excellence GR-Ex, 51 Avenue du Maréchal de Lattre de Tassigny, AP-HP Hôpitaux Universitaires Henri Mondor, 94010 Créteil, France * Correspondence: [email protected]; Tel.: +33-1-4981-2391; Fax: +33-1-4981-4943 K.R. and S.G. contributed equally to this work. y Received: 30 September 2020; Accepted: 16 November 2020; Published: 19 November 2020 Abstract: Acute chest syndrome (ACS) is a major complication of sickle-cell disease. Bacterial infection is one cause of ACS, so current guidelines recommend the routine use of antibiotics. We performed a prospective before–after study in medical wards and an intensive-care unit (ICU). During the control phase, clinicians were blinded to procalcitonin concentration results. We built an algorithm using the obtained measurements to hasten antibiotic cessation after three days of treatment if bacterial infection was not documented, and procalcitonin concentrations were all <0.5 µg/L. During the intervention period, the procalcitonin algorithm was suggested to physicians as a guide for antibiotic therapy. The primary endpoint was the number of days alive without antibiotics at Day 21. One-hundred patients were analyzed (103 ACS episodes, 60 in intervention phase). Possible or proven lung infection was diagnosed during 13% of all ACS episodes. The number of days alive without antibiotics at Day 21 was higher during the intervention phase: 15 [14–18] vs. 13 [13,14] days (p = 0.001). More patients had a short ( 3 days) antibiotic course during intervention phase: 31% vs ≤ 9% (p = 0.01). There was neither infection relapse nor pulmonary superinfection in the entire cohort. J. Clin. Med. 2020, 9, 3718; doi:10.3390/jcm9113718 www.mdpi.com/journal/jcm J. Clin. Med. 2020, 9, 3718 2 of 10 A procalcitonin-guided strategy to prescribe antibiotics in patients with ACS may reduce antibiotic exposure with no apparent adverse outcomes. Keywords: sickle-cell disease; acute chest syndrome; procalcitonin; antibiotic; bacterial infection 1. Introduction Sickle-cell disease (SCD) is globally one of the most common severe monogenic disorders. Patients with SCD are at increased risk of severe bacterial infection resulting primarily from reduced or absent splenic function. Acute chest syndrome (ACS) is a major complication of SCD, and a significant cause for morbidity and mortality in adult patients [1]. ACS is characterized by fever and/or respiratory symptoms with new pulmonary infiltrates. Bacterial infection is documented in only a minority of cases [1,2]. Since establishing a definitive etiology is not always possible, empirical antibiotic therapy is often used in ACS. National guidelines and expert consensus strongly recommend antibiotic therapy for almost all patients with ACS despite the low quality of the supporting evidence [3–5]. Procalcitonin is currently the most useful biomarker used to distinguish sepsis from other causes of inflammation and determine the bacterial origin of a pneumonia. Its concentrations are raised during bacterial invasion rather than viral infection [6]; its elevation magnitude correlates with infection severity, and decreasing levels over time correlate with infection resolution [7]. Procalcitonin guidance was previously reported as safe to reduce duration of antibiotic treatment in critically ill patients [8] and in those with community-acquired pneumonia [9]. We conducted this study to assess whether a procalcitonin antibiotic-prescribing guideline, implemented for the treatment of ACS, would result in less exposure to antibiotics than in usual care without a higher rate of adverse events. 2. Experiment Section 2.1. Study Design This was a single-center prospective observational before–after study of adult patients with SCD admitted for ACS to one of three medical wards or the intensive care unit of a French SCD referral center. ACS diagnosis was defined as an acute illness with fever and/or respiratory symptoms, accompanied by a new pulmonary infiltrate on a chest X-ray in a patient with genetically proven SCD. Exclusion criteria were severe immunosuppression (i.e., neutropenia, hemopathy, chemotherapy, and organ transplant), pregnancy or lactation, age less than 18 years, documented extrapulmonary infection, and antibiotics administered for more than 24 h before inclusion. The primary endpoint was the number of days alive without antibiotics at Day 21. Secondary endpoints included compliance to procalcitonin algorithm during the intervention phase, relapse, and superinfection. Good compliance to the algorithm was defined as a discontinuation of antibiotic therapy within 24 h after algorithm advice [8]. Superinfection was defined as the isolation from the same or another site of one or more pathogens different from that identified during the first infectious episode, together with clinical signs or symptoms of infection. Relapse was defined as the growth of one or more of the initial causative bacterial strains (i.e., same genus, species) from a second sample taken from the same infection site 48 h or more after stopping of antibiotics, combined with clinical signs or symptoms of infection. The following data were recorded: baseline characteristics (including type of hemoglobinopathy, steady-state hemoglobin value, history, and long-term treatment for SCD), triggering factors of ACS, documented bacterial or viral infection, treatment and outcome of ACS, and Sequential Organ Failure Assessment (SOFA) score, which quantifies organ dysfunction, and was used to adjust for patient severity. Rapidly progressive ACS was defined according to a previous publication [10]. J. Clin. Med. 2020, 9, 3718 3 of 10 2.2. Antibiotic Management Patients received antibiotics according to the current French guidelines for ACS [5], notably in case of fever above 38 ◦C or signs of sepsis. Procalcitonin concentration was assessed during the first three days of ACS using the electrochemiluminescence immunoassay on automatic analyzer Cobas 6000 e601 (Elecsys BRAHMS PCT, Roche Diagnostics, Meylan, France). The lower limit of detection of the assay was 0.02 ng/mL and functional assay sensitivity was 0.06 ng/mL. During the first period (March 2011 to January 2012) of the study (control phase), clinicians were blinded to procalcitonin-concentration results. At the control phase’s end, these measurements were used to build an algorithm by a panel of SCD experts. The intervention phase began when procalcitonin measurements were available in all wards of our institution (May 2015 to April 2016). During this intervention phase, the procalcitonin algorithm was suggested to physicians as a guide for antibiotic treatment, but the final decision to start or stop antibiotics remained at their discretion. Except for procalcitonin intervention, management of ACS was similar throughout the entire study. Patients received a standardized treatment protocol for ACS in accordance with current French guidelines [5]. 2.3. Documentation of Lung Infection Before introducing the antibiotics, we collected blood culture, sputum for gram stain and culture, and urine for Legionella pneumophila serogroup 1 and Streptococcus pneumoniae urinary antigen tests (BinaxNOW, Portland, ME, USA). Serologic tests for Mycoplasma pneumoniae (ELISA-Medac®, Wedel,
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